Bridging the rural divide

Take a sparsely populated state roughly the size of Kentucky and Tennessee combined, account for half a year's worth of turbulent weather, and consider a rapidly changing demographic attracted by a booming energy industry, and it immediately becomes clear why North Dakota treatment providers face serious challenges in engaging and retaining persons with urgent substance use-related problems.

The Bismarck-based Heartview Foundation has had to undergo significant change in its 50-year history to meet evolving needs. Operating a 100-bed inpatient facility in its early years, the nonprofit organization was forced by a combination of insurance pressures and geography to establish a broader continuum of services and support.

“There were so many folks in areas that had absolutely no services,” says Kurt Snyder, who was hired as a counselor at Heartview in 2002 and became its executive director three years later. “We had to be really creative.”

It becomes easy in discussing the addiction treatment community to focus on activity on the two densely populated coasts of the nation, while disregarding what's happening in most places in between. This tendency occurs despite the fact that more than half of the U.S. land mass is considered frontier or rural—and is characterized in part by a higher prevalence of substance dependence, mental illness, or comorbid disorders. Yet significant progress is being made in treatment in the nation's heartland, much of it surrounding effective use of technology to overcome barriers to treatment access and engagement.

Those providers that have made major strides in technology, such as Heartview Foundation, have learned an important lesson, however. They are coming to the realization that technology works best in cases when it enhances traditional care for substance use disorders, not necessarily when it replaces it.

“We found that people can't engage in the technology we use without establishing a rapport with us first,” says Snyder. “Face-to-face is so important initially.”

National data

According to national statistics, around one-quarter of the nation's population lives in rural or frontier areas. About 16 to 20% of this group is affected by substance dependence or mental illness or both, a proportion well in excess of what is seen in the rest of the country, says Nancy Roget, principal investigator with the National Frontier and Rural Addiction Technology Transfer Center (ATTC).

Roget says populations in rural and frontier communities have higher suicide rates and more serious alcohol and drug problems than their counterparts in urban/suburban regions, mainly because they have less access to prevention and early intervention services. Stigma also becomes magnified in regions where it is likely that only one care provider is available in the entire community, making it difficult to access services and maintain privacy at the same time.

“If a car is parked in front of the one provider in town, everyone will know,” says Roget. “Everyone knows your business.”

The National Frontier and Rural ATTC was established in 2012 as one of four specialty ATTCs to address focus areas of concern in the addiction field. Roget says it is important not to characterize the challenges in all rural and frontier areas as identical, both in terms of drug use trends and strategies to combat addiction. “The issues in rural Kentucky are different from those in South Dakota, or eastern Washington, or Hawaii,” she says.

But use of technology to overcome barriers to care certainly has emerged as a common thread in many of these communities, as the development of technological tools for substance use treatment and support begins to catch up to technology that has been applied to the rest of healthcare for a longer period.

“Some of the literature is showing that technology-based interventions are helping to decrease the [rural] divide,” says Roget.

Technology as extender

Much of Heartview Foundation's effort in technology drew from broad research findings pointing to the need for recovery-oriented systems of care nationally, says Snyder. Field historian William White's work has demonstrated that half of those individuals who complete an initial course of addiction treatment will relapse in the first year post-treatment, and for about 80% of them this will occur in the first 90 days after discharge. The question became, “How do we support patients beyond 4 to 8 weeks [of initial contact]?” says Snyder.

“We had people not completing our [20-session] aftercare program,” adds Beth Stroup-Menge, Heartview's project manager for a three-year Treatment Capacity Expansion grant that the organization received from the Substance Abuse and Mental Health Services Administration (SAMHSA) in 2013. The grant has allowed Heartview to continue to develop a Network Assisted Recovery (NAR) project that was launched in 2010 through the commercially available social network NING.

NAR is set up as a closed network, meaning that Heartview does not encounter the kinds of privacy concerns that it would face with a more accessible social network such as Facebook. In a typical scenario demonstrating its effectiveness in aftercare support, a Heartview counselor will post an educational blog on the network, and patients who read the post will then be given the opportunity to enter a gift card drawing. In order to be eligible to win the modest prize, however, the patient will have to be in attendance at the next face-to-face group session. Snyder says this encourages both extra contact with patients when they are at home and better in-person attendance for face-to-face sessions.